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Thrombocytopenic Purpura

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ICD-9: 287.31 ○ ICD-10: D69.3 Image not available.

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  • Thrombocytopenic purpura (TP) is characterized by cutaneous hemorrhages occurring in association with a reduced platelet count.

  • Occur at sites of minor trauma/pressure (platelet count <40,000/μL) or spontaneously (platelet count <10,000/μL).

  • Due to decreased platelet production, splenic sequestration, or increased platelet destruction.

    • Decreased platelet production. Direct injury to bone marrow, drugs (cytosine arabinoside, daunorubicin, cyclophosphamide, busulfan, methotrexate, 6-mercaptopurine, vinca alkaloids, thiazide diuretics, ethanol, estrogens), replacement of bone marrow, aplastic anemia, vitamin deficiencies, Wiskott–Aldrich syndrome.

    • Splenic sequestration. Splenomegaly, hypothermia.

    • Increased platelet destruction. Immunologic: autoimmune TP, drug hypersensitivity (sulfonamides, quinine, quinidine, carbamazepine, digitoxin, methyldopa), after transfusion. Nonimmunologic: infection, prosthetic heart valves, disseminated intravascular coagulation, thrombotic TP.

  • Skin Lesions. Petechiae—small (pinpoint to pinhead), red, nonblanching macules that are not palpable and turn brown as they get older (Fig. 20-1); later acquiring a yellowish-green tinge. Ecchymoses—black-and-blue spots; larger area of hemorrhage. Vibices—linear hemorrhages (Fig. 20-1), due to trauma or pressure. Most common on legs and upper trunk, but may be anywhere.

  • Mucous Membranes. Petechiae—most often on palate (Fig. 20-2), gingival bleeding.

  • General Examination. Possible CNS hemorrhage, anemia.

  • Laboratory Hematology. Thrombocytopenia.

  • Serology. Rule out HIV disease.

  • Lesional Skin Biopsy (usually can be controlled by suturing biopsied site) to rule out vasculitis

  • Differential diagnosis. Senile purpura, purpura of scurvy, progressive pigmentary purpura (Schamberg disease), purpura following severe Valsalva maneuver (coughing, vomiting/retching), traumatic purpura, factitial or iatrogenic purpura, vasculitis.

  • Management. Identify underlying cause and correct, if possible. Oral glucocorticoids, high-dose IV immunoglobulins, platelet transfusion, chronic ITP: splenectomy may be indicated.

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Figure 20-1.

Thrombocytopenic purpura Multiple petechiae on the upper arm of an HIV-infected 25-year-old male were the presenting manifestation of his disease. The linear arrangement of petechiae at the site of minor trauma is called vibices.

Graphic Jump Location
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Figure 20-2.

Thrombocytopenic purpura Can first manifest on the oral mucosa or conjunctiva. Here, multiple petechial hemorrhages are seen on the palate.

Graphic Jump Location
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Disseminated Intravascular Coagulation

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ICD-9: 256.8 ○ ICD-10: D65 Image not available.

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  • Disseminated intravascular coagulation (DIC) is a widespread blood clotting disorder occurring within blood vessels.

  • Associated with a wide range of clinical circum-stances: bacterial sepsis, obstetric complications, disseminated malignancy, massive trauma.

  • Manifested by purpura fulminans (cutaneous infarctions and/or acral gangrene) or bleeding from multiple sites.

  • The spectrum of clinical symptoms associated with DIC ranges from relatively mild and subclinical to explosive and life threatening.

  • Synonyms: Purpura fulminans, consumption coagulopathy, defibrination syndrome, coagulation fibrinolytic syndrome.

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Epidemiology

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Age of Onset
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All ages; occurs in children.

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Etiology and Pathogenesis

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  • Events that initiate DIC: Tumor products, crushing trauma, extensive surgery, severe intracranial damage; retained contraception products, placental abruption, amniotic fluid embolism; certain snake bites; hemolytic ...

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